| NPI | 1124070529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2018-01639) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 36966-020) |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2018-08-06 |